Intraoperative indocyanine green imaging for phlebosclerotic colitis with small bowel obstruction

Introduction: Phlebosclerotic colitis is a rare form of ischaemic colitis characterised by calcification and sclerosis of the mesenteric veins. It has been reported predominantly in Asian populations, although cases have also been described elsewhere. Clinical presentation is variable, ranging from asymptomatic disease to non-specific gastrointestinal symptoms and, in severe cases, intestinal obstruction or ischaemia. Intraoperative indocyanine green (ICG) fluorescence angiography is primarily used to assess tissue perfusion during colorectal surgery. Its potential utility in evaluating venous drainage and bowel viability in phlebosclerotic colitis has not been well established. We report a case of an elderly Asian man who required emergency surgery for intestinal obstruction and ischaemia associated with phlebosclerotic colitis, in whom intraoperative ICG was used as an adjunct to assess the perfusion of the remaining bowel and assist in determining the resection margin. Case presentation: An elderly male presented with a four-day history of abdominal distension, constipation and vomiting. Computed tomography scan of his abdomen and pelvis showed extensive mesenteric venous calcification in the ascending and transverse colon, with oedematous ileocecal valve resulting in small bowel obstruction. Following failure of conservative management, he underwent emergency surgery. Intraoperatively, the colon appeared thickened and ischaemic from the cecum to the transverse colon. ICG was performed to provide an additional assessment of bowel perfusion and to assist in determining the extent of resection. The patient underwent an open subtotal colectomy with defunctioning loop ileostomy, recovered uneventfully and was discharged on postoperative day 5. Histological examination demonstrated ischaemic colitis with venous sclerosis, calcification and ossification, compatible with phlebosclerotic colitis. Conclusions: This case illustrates the potential role of intraoperative ICG as an adjunct to conventional clinical assessment of bowel viability in phlebosclerotic colitis.